Healthcare Provider Details

I. General information

NPI: 1114651858
Provider Name (Legal Business Name): SAI SWARUPA REDDY VULASALA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2022
Last Update Date: 06/23/2023
Certification Date: 06/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 WEST 8 TH STREET C90, 2ND FLOOR CLINICAL CENTER
JACKSONVILLE FL
32209
US

IV. Provider business mailing address

655 WEST 8 TH STREET 2ND FLOOR CLINICAL CENTER, C90
JACKSONVILLE FL
32209
US

V. Phone/Fax

Practice location:
  • Phone: 904-244-4225
  • Fax:
Mailing address:
  • Phone: 432-999-1704
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberRTL22-0203
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: